First name:     Last name:     Age:     Birthdate:    
Grade entering in fall:     Allergies or other medical concerns:

First name:     Last name:     Age:     Birthdate:    
Grade entering in fall:     Allergies or other medical concerns:

First name:     Last name:     Age:     Birthdate:    
Grade entering in fall:     Allergies or other medical concerns:

First name:     Last name:     Age:     Birthdate:    
Grade entering in fall:     Allergies or other medical concerns:

Address:
City:     State:     Zip:

Parents name(s):
Email address:
Home phone:
Work phone:
Cell phone or pager:

In case of emergency, contact name:     Phone:
Relationship to child:

Transportation: If someone else is providing transportation other than yourself, the child can be released to or
Relationship to child:

Home church is:
I understand that a health form will be required for each child enrolled. Place "X"in box